Sexuality and Breast Cancer: Get Your Mojo Back

Lynn Wang, M.D.

February 12, 2014

Because Valentine’s Day is in February, many people start thinking about romance, love, and sex -- and their satisfaction with what they have. The February 2014 Breastcancer.org podcast features Lynn Wang, M.D., female sexual medicine specialist for the Main Line Health System and member of the Breastcancer.org Professional Advisory Board. She is a board-certified gynecologist and American Association of Sexuality Educators, Counselors and Therapists-certified counselor and educator. Listen to the podcast to hear Dr. Wang discuss:

different models of female sexual response

the biological, psychological, social, and relationship reasons why libido may be reduced

how a breast cancer diagnosis and treatment can affect libido and sexual satisfaction

who to talk to if you’re having sexual problems

Running time: 29:54

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Show Full Transcript

Jamie DePolo:
Hello, everybody. This is Jamie DePolo. I’m the senior editor of Breastcancer.org, and welcome to our February podcast. Today, I’m really happy. We have Dr. Lynn Wang, who is a female sexual medicine specialist. She practices with Mainline Health. Welcome, Dr. Wang.

Dr. Lynn Wang:
Thank you.

Jamie DePolo:
We’re so happy to have you here, and I’m curious, how did you become interested in that area of medicine, because it doesn’t seem like there are a lot of people who focus on that.

Dr. Lynn Wang:
Right. Well, I have been a gynecologist since 2002, so it’s been quite some time, and I found that in the office, what I was interested in talking about and what women were interested in talking about were basically about sex and relationships. As OB/GYNs, we’re not trained to address those issues, so I found myself asking more and finding out who could give me the answers, and ended up pursuing post-graduate training at University of Michigan to be a sexuality counselor, to address the sexual health issues of my patients.

Jamie DePolo:
Okay. And Valentine’s Day is in February, so that’s why we thought we’d focus on this topic, because thoughts of romance and love and sex and everything all seems to be tied into February, because of Valentine’s Day. I know we get comments on our discussion boards on the site, where people talk about, "Oh, this happened, that happened, this didn’t happen and I wanted it to." So, we thought this would be a perfect topic for the February podcast.
So, I know there are two models of female sexual response, and if you could go over those for us, and explain, because some women may have one, some women may have a combo, and people are thinking, “Well, I don’t have what I see on TV or anything, so there’s something wrong with me.”

Dr. Lynn Wang:
Yes. In fact, that’s what a lot of women come in, saying, “I don’t have desire,” or “I have low desire. I’ve always had low desire. Basically, what’s wrong with me?” I think that one of the most important things that women need to understand is that different women are wired differently. Meaning that some women are wired to have a female sexual response as.... Well, first of all, let’s back up. Female sexual response is basically the way how our mind and body responds to sexual stimulus. And so, some women respond in a very linear fashion, meaning they have, they start with desire, which leads to arousal, which leads to orgasm, and then resolution.
That was put forth by Masters and Johnson, so some people might be familiar with them. So, I liken that to the Disney ride, the roller coaster. What’s that big roller coaster, the one that everybody wants?

Jamie DePolo:
I’m really scared of them, so I don’t know.

Dr. Lynn Wang:
So, it’s like a roller coaster ride, right? There are many other types of sexual responses, but another common one is what’s called a cyclical response, meaning women don’t begin with desire, but given the right person, place, time, may be open to sexual activity, become aroused, which then hopefully leads to a positive sexual activity that is both emotionally connecting, physically connecting, which then makes them more open to future sexual activity. That was put out by Rosemary Basson, a sex therapist.
That’s been a more recent finding, so a lot of women actually don’t know about that, okay? Younger women tend to want to relate to that roller coaster way. Older women or women who have been in long-term relationships tend to relate to that circular model.

Jamie DePolo:
So, the roller coaster, if I’m understanding it right, it almost seems like that’s more physical, or is there still a large mental component?

Dr. Lynn Wang:
Yes, you're absolutely right. So, there is a strong biological component with the roller coaster model, as opposed to what I call the “It’s a Small World” model. They’re both magical, but in different ways.

Jamie DePolo:
The second one, the cyclical model, almost seems more mental, like it’s your brain or your mind that’s getting you into it, whereas the first one is very, “Ooh, I see, I want that.”

Dr. Lynn Wang:
Yes, and it has more to do with the goal. So, the goal for the cyclical model is more emotional and physical connection. So, it’s about what’s going on inside your head and what’s going on in between that space between you and your partner.

Jamie DePolo:
Okay, that makes sense.

Dr. Lynn Wang:
The problem is that a lot of entertainment and books and drug companies want to push the roller coaster model, and then you have a whole lot of women feeling like, “Well, how come I don’t have that, there’s something wrong with me.”

Jamie DePolo:
"I don’t have that reaction."

Dr. Lynn Wang:
“I don’t have that reaction," or maybe, “I did, but now I don’t.” The truth is that as long as you feel satisfaction with whatever activity you have, with yourself, with your partner, that’s all that counts. Now, if you’re not feeling satisfied -- and I’m not talking about orgasms or not orgasms, I’m just talking about satisfaction -- then that’s where there’s room for improvement.

Jamie DePolo:
Okay, so really, like many other things in life, you really shouldn’t compare yourself to anybody else, because everybody’s going to have a unique sexual response, in a way. Certainly, they would fall into these patterns or models, but what satisfies you may not satisfy somebody else, and what satisfies them may not satisfy you.

Dr. Lynn Wang:
That’s absolutely right.

Jamie DePolo:
Okay. Okay, so, I know you mentioned that younger women may tend to have the roller coaster model more, but say you’re a younger woman and you do have the more circular model. How does it change as we age? How does female sexual response change as women get older?

Dr. Lynn Wang:
So, we’re not entirely sure why, but it may be linked to multiple issues. From a biological standpoint, we know that testosterone levels peak when we’re in our 20s, and then they drop by 50% by the time we’re in our 40s, and then plateau after that. A lot of women think that their testosterone drops at menopause. That is not true, and in fact, that drop happened between the 20s and 40s. So, maybe there’s a link between testosterone and desire issues, although that link hasn’t been very clear in the studies, and with medication.
Then, there are issues with relationships. So, we know that as women transition from short-term relationships to long-term relationships, the desire levels go down, and that may be just from either being in a rut or finding other things that are much more important, like emotional connection, stability, things like that.

Jamie DePolo:
So, in other words, being in a stable relationship may be more important than having sex all the time, to distill it down in a way?

Dr. Lynn Wang:
Yeah, yeah. In other words, sex is not to have an orgasm. Sex is to have emotional and physical connection or stability or stress relief. Everybody’s different.

Jamie DePolo:
Sure. Okay, that makes sense. Now, any woman could have reduced libido, and again, we’ve seen some messages on our boards, specifically from women who’ve been diagnosed with breast cancer. But with menopause, as you said, with different hormones affecting it, really, any woman could have decreased libido? Is that very common, pretty much, that it’s going to happen?

Dr. Lynn Wang:
I wouldn't say it’s going to happen. It is very common, but only a small percentage of the women who have reduced libido are bothered by it, and that’s really the key. If you have decreased libido, and it’s not affecting you, your partner, your relationship, then we’d leave you alone. If it’s bothering you, that’s when we start to evaluate and consider treatment options.

Jamie DePolo:
Okay, and then, what are some of the reasons? I know you touched a little bit on hormonal issues, but are there other things that can affect your libido?

Dr. Lynn Wang:
Absolutely. So, things like medications are a big one.

Jamie DePolo:
What kinds?

Dr. Lynn Wang:
Antidepressants are known for affecting libido. Other types of medications for high blood pressure, diabetes, and even those medical conditions can contribute to libido issues.

Jamie DePolo:
So, all things also come on as we age, so it’s like a double-whammy, almost.

Dr. Lynn Wang:
Exactly, exactly. Then, from the psychological standpoint, things like depression, anxiety, history of trauma and abuse can absolutely contribute. Stressors, common, everyday stressors of caretaking, job loss, absolutely contribute. Grieving can contribute. Social issues, meaning the attitudes and beliefs we had regarding sexuality, absolutely, how you are taught to look at sex, approach sex, absolutely affects how you approach and look at sex as an adult.

Jamie DePolo:
Okay. Do you think that changes for a lot of people?

Dr. Lynn Wang:
Yes, absolutely, absolutely. We’re wired to change and adapt, and I think that if you were raised in a sex-negative upbringing, it doesn’t mean that you’re going to be sex-negative. It’s just one component in many. Then, there are relationship issues, and when I say that, I mean past and present relationships can absolutely affect it. If you’re feeling emotionally connected, physically connected, that’s a positive thing, but if you’re having marital discord, if you’re having attraction issues, communication issues, then those can contribute to desire problems.

Jamie DePolo:
It all plays into it, which makes sense.

Dr. Lynn Wang:
Yeah, and so, a lot of women that come in, they have multiple issues, and they’re not sure which one’s more important and how to sort through it. That takes time to go through. Often, one issue affects all the other issues, and so, it does take time to work through those and to figure out which one’s more important and which one takes precedence.

Jamie DePolo:
Okay. Now, if you then throw a breast cancer diagnosis on top of all these other issues, which I’m assuming then, so you’ve got stress, I’m sure, that comes with the diagnosis. You have treatments that, I’m also assuming, can affect libido. I know you mentioned the antidepressants, and in some cases, antidepressants are used to alleviate some of the side effects from hormonal therapies and things, but are there other known, how do I want to say it -- other treatments, are they known to affect sexuality?
I’m assuming when you’re undergoing chemo, your body is so wiped out that, yes, libido is probably the farthest thing from your mind. Are there other things that we should talk about?

Dr. Lynn Wang:
So, I think that when you bring breast cancer into the mix, it brings a whole host of other issues. We know that chemotherapy agents, radiation agents, those long-term therapies all affect sexuality. And, unfortunately, unlike all the other after-effects of breast cancer treatments, sexual issues often either get worse or stay the same. So, that’s why it becomes all the more important to address these issues, especially as you go through the treatment process.

So, to me, when somebody has breast cancer, and with sexual issues, it’s like the same idea of somebody who’s just been in a massive car accident, and you’re asking them to ride that roller coaster or ride that “It’s a Small World” ride. They’re just not in that mental space to go there. So, my approach is to think of things more in terms of looking at your sexual health when you have breast cancer. We need to address all those biological, psychological, social, relational issues, but one way to look at it is to think about your relationship with yourself or with your partner.
I’m going to bring up an image, which would be an egg. The whole point of this image is to think of your relationship with yourself or with another person in the frame of sexual health, meaning when we assess somebody or their relationship for sexual health, we look at the outer eggshell. Let’s call that physical connection, okay? When we look at physical connection, what we’re looking for is whether there is satisfaction with the sexual activity, meaning are you satisfied with yourself, with your partner, with you as a couple.
The other thing we look for is eroticism, and what I mean by that is, do you know and can you communicate what you like, when you like it, how you like it, basic communication issues.

Jamie DePolo:
I think that’s tough for a lot of people, because they don’t know how to say what they want.

Dr. Lynn Wang:
Even before the breast cancer. The other two things that we look for are whether you have positive, realistic goals. Meaning, we’re not looking for Fifty Shades of Grey sex, right? We’re looking for something that is generally good most of the time, and sometimes it just isn’t, but generally good. Then, the last thing we look for is whether you have the ability to expand your definition of sex. In other words, the traditional approach is to define sex as penetrative sex.
The problem with that is as women get older, there is vaginal dryness issues, pain issues. For men, they have erectile issues, and of course, let’s not leave out same-sex couples. There’s usually issues that come with aging, and so, it’s going to be more important as we age to make sure that we include outercourse along with intercourse, so that our satisfaction level is not hung up on something that probably, or might not work.

Jamie DePolo:
Okay, that makes sense.

Dr. Lynn Wang:
So, these are not my ideas. These are ideas of famous sex therapists from all over the world. I grew up in the generation of “MacGyver.” I love “MacGyver.” He can take a tampon and a pinwheel, and he can make a bomb. So, I like taking lots of different ideas together, and so, just so they don’t get mad at me, during McCarthy and Sallie Foley and Peggy Kleinplatz. There's too many. But anyways, there's a lot of --

Jamie DePolo:
It’s like a smorgasbord of different ideas that can all be pulled in to help people.

Dr. Lynn Wang:
Right, right. These are not my ideas. The egg is my idea. So, anyway, so we go back to the shell, and we want to make sure that that shell is strong. But at the core, the really, really important stuff is whether a couple or an individual is emotionally connected. When I say “emotionally connected,” I mean the stuff -- so Sue Johnson is a famous couple’s therapist that founded emotionally focused therapy, couple’s therapy. I love her definition of emotional connection, which is asking yourself, “Do I matter to that person? Can I turn to that person? Can I lean on that person?” That can be, if you don’t have a partner, that can be turned inward, too.

Jamie DePolo:
Oh, ok. “Can I trust myself? Can I lean on myself?”

Dr. Lynn Wang:
Yes. That’s not an easy answer for some people.

Jamie DePolo:
I could see why that would be difficult.

Dr. Lynn Wang:
So, let’s consider that as a yolk. That’s the really, really important stuff. And I think that when couples or individuals are distressed, we need to really focus on that emotional connection. So, for women with breast cancer, sometimes what women have told me is, “I’m not in my body.”

Jamie DePolo:
“My body’s become a foreign thing to me.”

Dr. Lynn Wang:
“It’s just a vehicle at this point. I’m here from the neck up.” So, part of therapy is encouraging women to come back into their body, and that relates to the emotional connection, okay? So, you have these two layers. You have the emotional connection, the yolk, and then you have the physical connection, which is the shell. To me, that white stuff in the middle is touch. So, touch is what connects the emotional and the physical connection. So, a lot of women have told me, “Okay, I won’t even let him touch me because I’m afraid it’s going to end up in penetrative sex, and that’s going to hurt, so we don’t even do anything.”
So, part of the process is re-learning all the different levels of touch. So, touch can be just simple hugs and kisses, holding hands, all the way to massages, or all the way to sensual touch.

Jamie DePolo:
Now, I’ve seen several discussions on the boards where women who have been diagnosed and who had surgery say, “My partner is afraid to touch my breasts. He or she doesn’t want to hurt me.” Or the person feels like they're -- It goes along with doesn’t want to hurt you, but it’s become this thing, this area that’s of concern. So, how do you work with that, because that seems like a hard thing to overcome.

Dr. Lynn Wang:
Yes. So, my advice would be to go slow and go back to basic touch of not necessarily even your breasts. I would start with touching parts of the body that are okay. In other words, let’s just start with foot massages, hand massages, face massages, scalp massages. Let’s work with just being okay with touch, being okay to the point that you’re actually enjoying that touch.

Jamie DePolo:
Both people, too, right?

Dr. Lynn Wang:
Enjoying giving and receiving, right? And the other thing that’s important to note is that we, as humans, we are wired to adapt. So, let’s take advantage of that, right? So, what many women have told me is that they have found new spots of sensitivity, new erogenous zones. So, it’s time to explore, if you’re okay with that, in a gentle way. You don’t have to start at the breast. It could be anywhere else, and explore, but in a gentle way.

Jamie DePolo:
Okay, and then gradually, if both people are comfortable with it, keep expanding the areas.

Dr. Lynn Wang:
Absolutely, absolutely.

Jamie DePolo:
I know it seems like the breast, at least the female breasts, are so sensationalized, sexually, in a manner, because of whatever popular culture, that if the breasts are not involved, then it seems weird. I think that’s what a lot of people think, because you see whatever, magazines and ads and everything, they’re right there. The breasts are right there. So, to not have them involved in the sexual act, whatever the sexual act is, I think, may be strange for some people. But the whole idea of finding these new areas that are pleasurable makes a lot of sense.

Dr. Lynn Wang:
I would say, “Don’t worry about what other people and the magazines say, or the books say.” I would say, “Focus back on that feeling in your gut of things feeling good, and try to think about when was the last time that you felt good, and focus back to -- pay attention to where in your body you feel that, and think of it as a thread. You want to go back to that thread and pick up from where you left off. Focus back into your body, and use that as a compass of what feels good to you and what doesn’t.”

Jamie DePolo:
Now, I’m just curious. If I’m a woman, I’ve been diagnosed. I’m seeing a lot of doctors, and I feel like I’m not happy with my sex life or my libido. Who do I talk to about this, because I’ve got an oncologist, I’ve got a GP, I’ve got this person, I’ve got that person, I’ve got nurses. And it’s not an easy topic for a lot of people to talk about. So, how do I start?

Dr. Lynn Wang:
I think a good place to start is your gynecologist, quite frankly. Even though most OB/GYNs are not trained to address sexual issues per se, they are a good place to start, because at the very least, they can rule out things like vaginal dryness and treat that, the biological causes. Then, if they’re not comfortable, know that you can always ask for a referral to, say, a sex counselor or a sex therapist. So, sex counselors are usually people in the healthcare provider world, and they can be nurses, physicians, nurse practitioners. Sex therapists are in the mental healthcare world, and they are therapists, psychologists, people like that.

Jamie DePolo: That specialize in sex.

Dr. Lynn Wang:
Specialized in sex, and a lot of women say, “What’s the difference between them?” The difference is the difference between the healthcare world and the psychological world, one, but two, sex counselors in the healthcare world can examine patients, if it’s within their scope of practice -- meaning me, as a gynecologist, I can examine patients if I think there’s some sort of biological issue.

Jamie DePolo:
So, a therapist couldn’t examine you, but could they say, “You know, I think there’s also something physical going on that you need to see a gynecologist”?

Dr. Lynn Wang:
Yes, sex therapists are ethically bound not to examine patients, but they are trained to work closely with healthcare providers to work in a multi-disciplinary fashion. So, I am called a female sexual medicine specialist, which is a lay term. It just means a physician that has had training in sexual health. A good place to go to is websites like AASECT, A-A-S-E-C-T. That’s the American Association of Sex Educators, Counselors, and Therapists.org.

Jamie DePolo:
That’s a mouthful. Could you say that one more time?

Dr. Lynn Wang:AASECT.org. If you go there, you’ll find ones that are certified, certified sex therapists, educators, and counselors in your local area. There are many other websites that you could refer to. Another one is SSTAR, [SSTARnet.org]. Then, if you’re looking for a good therapist, then you can look on the American Psychological Association, APA.org, good couple’s therapists you can find there. Then you can go to ICEEFT, [ICEEFT.com], to look up the emotionally focused couple’s therapy.

Jamie DePolo:
What is ICEEFT stand for? If you don’t remember, that’s fine. I don’t want to put you on the spot.

[Editor's Note: ICEEFT stands for the International Centre for Excellence in Emotionally Focused Therapy.]

Jamie DePolo:
Okay. Now, I’m curious, too, especially when we talk about the couples. What if my partner doesn’t want to go? I’m perceiving a problem, I’m not happy or satisfied, but the partner says, “You know, it’s okay. It’ll probably get better. Let’s just give it some time.” Is it worthwhile for just me to go?

Dr. Lynn Wang:
Absolutely, absolutely, because there are so many things that we can work on as an individual, and sometimes it just takes a while for the partner to come around. It’s okay.

Jamie DePolo:
It’s okay, all right. That’s good. Let’s see. So, we talked about who to see. I’m trying to think. That’s about all my questions for now. We’ve covered quite a bit. Is there anything else you’d like to add or close with?

Dr. Lynn Wang:
No. I just want women to know that there is definitely help out there, and there are people that are ready and willing to help. You just have to reach out, and sometimes you have to be a little bit more proactive in looking for these people.

Jamie DePolo:
Okay. So, yeah, the bottom line is, don’t suffer in silence. We know it’s a difficult topic to bring up sometimes, but there’s no embarrassment, and if you’re not happy, you should get help.

Dr. Lynn Wang: Just ask.

Jamie DePolo: Just ask. All right. Thank you very much, Dr. Wang. It’s been wonderful to have you as our guest, and I’m hoping you’ll come back before next February, and we’d like to thank everybody for tuning in to this Breastcancer.org podcast, and we hope you tune in to our next one.